REVIEW Template to Perpetrate: An Update on Violence in Autism Spectrum Disorder David S. Im, MD Introduction: For the past two decades, researchers have been using various approaches to investigate the relationship, if any, between autism spectrum disorder (ASD) and violence. The need to clarify that relationship was reinforced by the tragic mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, in December 2012 by an individ- ual diagnosed with Asperger’s syndrome. The purpose of this article is (1) to provide an updated review of the literature on the association between ASD and violence, and (2) to examine implications for treating, and for preventing violence by, individuals with ASD. Method: A review of all published literature regarding ASD and violence from 1943 to 2014 was conducted using electronic and paper searches. Results: Although some case reports have suggested an increased violence risk in individuals with ASD compared to the general population, prevalence studies have provided no conclusive evidence to support this suggestion. Among individuals with ASD, however, generative (e.g., comorbid psychopathology, social-cognition deficits, emotion-regulation problems) and associational (e.g., younger age, Asperger’s syndrome diagnosis, repetitive behavior) risk factors have been identified or proposed for violent behavior. Conclusions: While no conclusive evidence indicates that individuals with ASD are more violent than those without ASD, specific generative and associational risk factors may increase violence risk among individuals with ASD. Further re- search would help to clarify or confirm these findings, suggest potential directions for evaluation, treatment, and preven- tion, and potentially provide compelling empirical support for forensic testimony regarding defendants with ASD charged with violent crimes. Keywords: Asperger’s syndrome, autism spectrum disorder, autistic disorder, pervasive developmental disorder, violence he tragic shooting of 20 children and 6 adults at instances of violence committed by individuals with known Sandy Hook Elementary School in Newtown, Con- or suspected ASD have been reported in the mental health 2–27 13 Tnecticut, in December of 2012 by Adam Lanza, an in- literature and in the media. Over the last two decades, dividual diagnosed with Asperger’s syndrome (AS), has the interest in this topic has increased, but research has reinforced the need to clarify the relationship, if any, between yielded inconsistent or, at best, inconclusive evidence regard- autism spectrum disorder (ASD) and violence. Violent behav- ing any association between ASD and violence. ior by individuals with ASD has been noted as early as 1944, ASD symptoms were first described by Leo Kanner in 1(p 40) when Hans Asperger described the case of Fritz V., a 1943 in his report of young children displaying a lack of affec- boy with severe social-interaction deficits who would quickly tive contact with others, muteness or abnormalities of language, lash out at peers “with anything he could get hold of (once intense resistance to changes in routine, and a fascination with with a hammer), regardless of the danger to others.” Other atypically manipulating objects. He called this condition early infantile autism. One year later, Hans Asperger reported in German on a group of boys with significant social problems From the University of Michigan Medical School and Center for Forensic and idiosyncratic interests but with normal cognitive skills. Psychiatry, Saline, MI. He used the term autistic psychopathy to connote this Original manuscript received 14 May 2014, accepted for publication subject pattern of deficits. While diagnoses capturing Kanner’sand to revision 5 December 2014; revised manuscript received 6 January 2015. Asperger’s descriptions (autistic disorder and Asperger’sdisor- Correspondence: David S. Im, MD, 8303 Platt Rd., Saline, MI 48176. Email: email@example.com der, respectively) were included as discrete entities in the fourth © 2016 President and Fellows of Harvard College. This is an open-access ar- edition of the Diagnostic and Statistical Manual of Mental ticle distributed under the terms of the Creative Commons Attribution-Non Disorders (DSM-IV), the two conditions were subsequently Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi- collapsed into the single designation of autism spectrum dis- ble to download and share the work provided it is properly cited. The work 30 30 cannot be changed in any way or used commercially. order in DSM-5. The DSM-5 criteria for ASD require per- DOI: 10.1097/HRP.0000000000000087 sistent deficits in social communication and interaction along 14 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD with restricted patterns of behavior, interests, or activities, METHOD beginning in the early developmental period and causing sig- Using electronic databases (PsycINFO, PsycARTICLES, nificant functional impairment; intellectual and language MEDLINE) and article searches (the latter based on reviews impairment may or may not be present. of reference lists), all published literature was searched using It is important to distinguish ASD from other disorders the terms autism, autistic disorder, high-functioning autism, that can present with social-interaction abnormalities and autistic spectrum disorder, Asperger’s, Asperger’s disorder, restricted interests. For example, individuals with schizoid Asperger’s syndrome, and pervasive developmental disorder, personality disorder typically present with isolation due to all individually cross-referenced with the terms violence, ag- disinterest in interpersonal relationships, and individuals with gression, murder, rape, assault, criminal, crime, and offending, schizotypal personality disorder commonly present with acute from 1943 to 2014. Only reports describing violent behavior discomfort with close relationships, and with magical thinking. in association with ASD were included for analysis. Reports Although similar in some respects to these other two disorders, excluded from analysis included (1) those not published in ASD differs in others. Compared to people with schizoid per- English, (2) those focused on behavior that did not involve sonality disorder, those with ASD often have a desire to make violence toward others, (3) those in which no clear diagno- friends or have intimate relationships, but their profound sis of ASD was made for the individual(s) in question, and social-skills deficits render them unable to appropriately en- (4) those whose objective did not specifically relate to clarify- gage, empathize with, or respond to others. And compared ing the relationship between violence and ASD, including to people with schizotypal personality disorder, the social- those focused on treatment. interaction difficulties of those with ASD are rooted in em- The original electronic search yielded 1396 reports. Based pathic and perspective-taking deficits rather than excessive on a review of titles and abstracts, 1327 of these were ex- social anxiety associated with paranoid fears. In addition, cluded (91 were not published in English; 426 did not focus the preoccupations of individuals with ASD usually involve on violence toward others; 746 involved no clear ASD diag- themes (e.g., weather reports, sports statistics) that, while un- nosis for the individual(s) in question; and 64 were treatment usual in intensity or focus, are not typically bizarre or magi- focused). The remaining 69 reports were subsequently ordered cal, unlike what happens in schizotypal personality disorder. and reviewed in full. Based on this further review, another 16 For purposes of this review, the phrase autism spectrum records were excluded (four did not address violence toward disorder (ASD) refers to conditions meeting DSM-5 criteria others; five did not focus on individuals with ASD; and eight 31 29 for autism spectrum disorder, DSM-IV-TR or DSM-IV did not relate to clarifying the relationship between violence criteria for autistic disorder, Asperger’s disorder, or pervasive and ASD [for example, one was an editorial letter with a developmental disorder not otherwise specified (PDD-NOS), treatment focus; another was a book review that was felt International Classification of Diseases, tenth revision (ICD-10) not to contribute relevant information on ASD and violence; criteria for autistic disorder or Asperger’s syndrome, or and a third examined the moderating effect of aggression Gillberg and Gillberg criteria for Asperger’s syndrome.* and social understanding on anxiety levels in individuals with Violence is defined as intentional threats, attempts, or inflic- ASD as a function of IQ and did not specifically have aggres- tion of bodily harm on another person. sion as its focus]). This process resulted in the inclusion of 53 According to the Centers for Disease Control and Pre- reports from the electronic search. Analysis of reference lists vention, the prevalence of ASD among eight-year-old chil- from these reports resulted in an additional 12 articles being dren in the United States in 2010 was 1.47%, representing ordered and reviewed, with the consequence that, in total, a 30% increase from 2008 estimates (1.14%). The recent 65 articles were reviewed and used to study the association increase in ASD prevalence further underscores the need to between ASD and violence. Figure 1 presents a schematic of clarify the relationship between ASD and violence. the search process for this review. Efforts in this regard have been under way for over two de- cades, using a variety of research approaches. The purpose of RESULTS this article is to (1) provide an updated review of the literature Studies on the association between ASD and violence can be on the association between ASD and violence, and (2) exam- grouped into three categories: (1) descriptive case reports, ine implications for treating, and for preventing violence by, (2) prevalence studies, and (3) reviews with theoretical expla- individuals with ASD. nations for violence in individuals with ASD. *The Gillberg and Gillberg criteria were the first diagnostic criteria for AS. They Descriptive Case Reports closely resemble Asperger’s original description, and require difficulties in six do- Table 1 summarizes the descriptive case reports that were re- mains, including reciprocal social interaction, narrow interests, imposition of rou- tines and interests on self or others, speech and language problems (including viewed regarding violence in individuals with ASD. delayed development, formal/pedantic language, or odd speech prosody), nonver- A total of 27 case reports involving 48 individuals were bal communication, and motor clumsiness. These criteria differ from DSM-5 and 32 identified, providing a detailed description of violent be- ICD-10 criteria in that the latter do not require speech/language abnormalities and motor clumsiness, and preclude the presence of language and cognitive delays. havior associated with ASD. As seen in Table 1, the majority Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 15 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Figure 1. Schematic of search process for review of ASD-violence relationship. of individuals in these reports had a diagnosis of AS. The population, violence risk is also increased by substance abuse, 1–4,6,8–10,12,19,23–27 22 violence included physical assaults, sexual only one of the case reports cited this factor as relevant to 6–8,11–13,18,20 5,12,18,22 13,14,16,17,21 assaults, arson, murder, and the violence described. 15,19,23 stalking/violent threats. While these descriptive reports are helpful in raising Many of these reports posit features of ASD that could awareness of, and plausible mechanisms behind, violent be- increase the likelihood of violent behavior, such as im- havior in ASD, they do not constitute systematic attempts to paired abilities (or the application thereof) to understand clarify whether individuals with ASD are more violent than and appreciate others’ mental states (impaired theory-of- others, or what factors in those with ASD increase violence 3–8,11,12,18 mind abilities); difficulty appropriately perceiving risk. Prevalence studies have aimed to more adequately ad- 2,18,19 4,13,18,22 nonverbal cues; and intense, restricted interests. dress these questions. Other case studies have highlighted comorbid psychiatric disorders as increasing violence risk in ASD, including Prevalence Studies 15 13,15 attention-deficit/hyperactivity disorder, depression, bipo- Table 2 summarizes prevalence studies to date that have ex- 10,15,25 21,27 lar disorder, psychotic disorders, and personality amined the relationship between ASD and violence. Seventeen 13,26 15 disorders. Although Palermo notes that in the general such studies were identified. 16 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD Table 1 Descriptive Case Reports of Violence Associated with Autism Spectrum Disorder Study Diagnosis Nature of violent behavior Comments Asperger (1943) Asperger’s syndrome Physical assaults on peers “Pronounced destructive urge,” severe social-interaction deficits Mawson et al. Asperger’ssyndrome(41 y.o. Physical assaults: entered neighbor’s People w/Asperger’s syndrome unable (1985) man in high-security hospital) house with knife when angered to perceive meaning or implications of by her dog’s barking & struck her others’ nonverbal behavior; many violent w/screwdriver; assaulted crying people admitted to secure units may have child at railway station by placing hands undiagnosed Asperger’ssyndrome over child’s mouth to stop noise of crying Baron-Cohen Asperger’ssyndrome Physical assaults on 71-year-old Violence due to “social cognitive deficit” (1988) (21 y.o. man) girlfriend consisting of inability to appreciate others’ mental states; people w/Asperger’s syndrome may end up in secure settings due to violence Tantum (1988) Autism & Asperger’s Physical assaults on mothers (9 subjects) Violent subjects felt to have no empathic syndrome (majority of a for trivial reasons (e.g., food not ready grasp of victim’s distress sample of adults w/lifelong when expected) eccentricity & social isolation) Physical assaults on others in context of morbid preoccupation with violence (3 subjects) Everall & Asperger’ssyndrome Arson (repeated acts) Empathic deficits & anxiety over future Lecouteur (1990) (17 y.o. boy) placement were factors in fire-setting behavior Chesterman & Asperger’s syndrome Physical assault on police officer who Intense, obsessional interests thought to Rutter (1993) accused him of theft while he was in underlie violent behavior another person’s home watching lingerie spinning in a washing machine Cooper et al. Asperger’ssyndrome Sexual assault of female stranger on bus Empathic & perspective-taking deficits, (1993) (38 y.o. man) combined with sexual preoccupations, were related to behavior Kohn et al. (1998) Asperger’ssyndrome Physical assaults on young boy & old man Based on a computerized test of (16 y.o. boy) understanding social situations, impaired Sexual assaults (grabbed female application of theory-of-mind abilities is stranger on street, tried to undress her, problematic in persons with Asperger’s touched breast/genitals; later explained syndrome—rather than impaired behavior as his expression of fondness theory-of-mind abilities per se & way of making her his girlfriend) Bankier et al. Asperger’ssyndrome Physical assaults on mother Diagnosis of Asperger’s syndrome missed (1999) (26 y.o. man) through multiple hospitalizations, despite severe social-interaction impairment & restricted, repetitive patterns of behavior for 14 years Frazier et al. Asperger’s disorder (13 y.o. boy) Physical assaults on siblings & others Comorbid bipolar disorder was significant (2002) factor that increased risk of violence Milton et al. Asperger’s syndrome Sexual assault Empathic deficits & sexual (2002) preoccupations were related to behavior Continued on next page Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 17 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Table 1 Continued Study Diagnosis Nature of violent behavior Comments Murrie et al. Asperger’ssyndrome Arson (set fire to numerous homes as Intense preoccupation with those who (2002) (31 y.o. man) means of exacting revenge on schoolmates had wronged him was critical in driving who had harassed him during youth; fire-setting behavior no actual relationship between homes & these peers, but trivial details of homes reminded him of peers) Asperger’ssyndrome Sexual assault on male minor Intense sexual preoccupations, poor social (27 y.o. man) skills & vulnerability to manipulation were possible factors in offense Asperger’ssyndrome Physical assault (attempted murder; Intense, restricted interests, cognitive (44 y.o. man) shot psychologist involved in child inflexibility & impaired abstract thinking custody evaluation in head) were possible factors in violence Asperger’ssyndrome Sexual assault on 9 y.o. daughter Intense, restricted interests, empathic (33 y.o. man) &her peer deficits & comorbid pedophilia were factors in offense Asperger’ssyndrome Sexual assault Empathic & severe social-interaction (22 y.o. man) deficits were noted Asperger’ssyndrome Physical assault (on two women at Empathic & severe social-interaction (31 y.o. man) a zoo restroom) deficits, along w/intense & aggressive sexual fantasies, were factors in offense Silva et al. (2002) Asperger’s syndrome Serial homicide & sexual assault Deficits in theory of mind, empathy & social reciprocity, along w/restricted/ repetitive interests & comorbid psychopathology, formed foundation for sexual serial-killing behavior Silva et al. (2003) Asperger’s syndrome Murder (multiple victims in bombing Theory of mind, empathy & social of public building) reciprocity deficits, along w/restricted interests, were factors in violence Palermo (2004) PDD-NOS (19 y.o. man) Threat to kill police officer Comorbid ADHD drove trespassing & window-peering behavior that led to police involvement Asperger’ssyndrome Threat to burn down grandmother’s home Comorbid depression & anxiety about (33 y.o. man) possible change in living arrangements drove behavior Asperger’ssyndrome Sexual assault of prepubescent boy Hypersexuality in context of manic (30 y.o. man) episode and interpersonal intrusiveness related to autism spectrum disorder were major factors in behavior Schwartz-Watts Asperger’sdisorder Murder (shot 8 y.o. boy who had run Tactile/sensory hypersensitivity was (2005) (22 y.o. man) over his foot w/bicycle) significant factor in violence Asperger’sdisorder Murder (shot victim numerous times (35 y.o. man) after victim struck him in face, hitting his glasses) Asperger’sdisorder Murder (shot girlfriend’sfatherwho Misinterpretation of nonverbal social cues (20 y.o. man) was attempting to return some belongings was factor in violence; history of sensory to him; misread victim’s facial expression hypersensitivity (e.g., sound of radio) as intending to harm him) Continued on next page 18 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD Table 1 Continued Study Diagnosis Nature of violent behavior Comments Silva et al. (2005) Asperger’s syndrome Murder (serial homicide) Deficits in theory of mind, central coherence, empathy & social reciprocity, along w/restricted interests & paraphilic tendencies, were all factors in violence Haskins & Silva Asperger’s syndrome Arson (fire killed daughter) Theory-of-mind deficits, poor social (2006) reciprocity, or restricted, narrow interests were factors in offending in all three cases Asperger’s syndrome Sexual assault (inappropriate touching of female students) Asperger’s syndrome Sexual assault (male strangers in public restrooms) Katz & Zemishlany Asperger’ssyndrome Threats to kill female stranger whom Significant deficits in social (2006) (38 y.o man) he had fallen in love with because understanding, cognitive flexibility & eyes happened to meet empathy in all three cases Asperger’ssyndrome Physical assaults on family members (22 y.o. man) Asperger’ssyndrome Threats to a girl (30 y.o. man) Physically assaultive at home Griffin-Shelley Asperger’ssyndrome Sexual assaults on younger children Comorbid anxiety & sexual compulsions (2010) (14 y.o. boy) fueled behavior Murphy (2010) Autism spectrum disorder Murder (stabbed & killed work Theory-of-mind & empathy deficits, poor (21 y.o. man) supervisor whom he blamed for emotion regulation (anger at teenagers overcriticizing his work & reporting him taunting him, anxiety about losing job), to the restaurant manager after he overly rigid adherence to rules/routines punched a teenage girl for taunting & comorbid psychotic symptoms were him at work) all factors in violence Radley & Autism spectrum disorder Arson Social-skills deficits, restricted interests Shaherbano (2011) (24 y.o. man) Physical assaults (fires, witchcraft), comorbid psychotic symptoms & comorbid alcohol abuse all contributed to violent behavior Tochimoto et al. Asperger’s disorder Physical assaults on men who reminded Clear recall & present reexperiencing (2011) (16 y.o. boy) him of peer who had bullied him years ago of trivial events from many years ago & associated feelings (“time-slip” Asperger’s disorder Threats to hurt neighbor with sword phenomenon) thought to underlie (27 y.o. man) due to annoyance from past memory violence of neighbor throwing away cigarette butt in front of home White et al. (2011) Autism spectrum disorder Grabbing & biting when particular toy In both cases, aggression was maintained (autism, 7 y.o. boy) visible but not available by access to toy that was then used to engage in repetitive (stereotypical) Autism spectrum disorder Grabbing & pulling when particular behavior (autism, 7 y.o. boy) toy visible but not available Singh & Coffey PDD-NOS (17 y.o. boy) Physical aggression toward caregivers Disruption of routines triggered violence; (2012) & others comorbid bipolar disorder drove hypersexual behavior Baliousis et al. Autism spectrum disorder Physical assault on girl who Poor emotion regulation (anxiety & vengeful (2103) (21 y.o. man) transferred affections elsewhere anger), misinterpretation of others’ verbal & (stabbed with two knives, nearly fatal) nonverbal behavior, & comorbid personality disorder were factors in violent behavior Frank (2013) Asperger’ssyndrome Physical assaults on mother Poor emotion regulation & comorbid (11 y.o. boy) psychotic symptoms raised violence potential ADHD, attention-deficit/hyperactivity disorder; PDD-NOS, pervasive developmental disorder not otherwise specified. Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 19 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Table 2 Prevalence Studies Examining Relationship Between Autism Spectrum Disorder and Violence Study Study type Violence-detection Subjects Comparison Findings method group w/o ASD? Ghaziuddin et al. Review of all published Review of published Individuals w/AS No Violence in 2.27%–5.58% (1991) reports on clinical articles on individuals of individuals; since features of AS from w/AS to see if history rate is similar to that in 1944 to 1990 of violent behavior general population, no (n = 132 patients) was documented special association between AS & violence Scragg & Shah Screening of all male Subjects were Maximum-security No AS in 1.5%–2.3% of (1994) patients in residing in secure inpatients being maximum-security maximum-security hospital (study screened for AS inpatients; since rate is forensic hospital population violent) significantly higher than (n = 392) for AS that in general population (0.36%), AS overrepresented in forensic settings; possible increased violence risk in AS Hare et al. (2000) Screening of all male Subjects were residing Maximum-security No ASD in 2.4%–5.3% of patients in 3 in secure hospital inpatients being maximum-security maximum-security (study population screened for ASDs inpatients; since this forensic hospitals violent) rate is significantly (n = 1305) for ASD; higher than ASD rate in initial ASD screening general population questionnaire followed (0.71%), ASD by chart review overrepresented in forensic settings Siponmaa et al. Retrospective review Subjects were 15–22 y.o. offenders No Definite ASD in 15%; (2001) of presentencing violent offenders referred for presentencing definite AS in 3%; thus forensic psychiatric referred for forensic psychiatric ASD overrepresented investigations of presentencing investigations being among offenders offenders over 5-year forensic psychiatric screened for ASD referred for pre-sentencing period in Sweden investigations (including AS & forensic psychiatric (n = 126) PDD-NOS) investigations Soderstrom et al. Screening of adults Subjects were under Adult inpatients No Autism in 5%; AS in (2005) admitted by court prosecution for severe (17–76 y.o.) under 3%; atypical autism in order to forensic violent/sexual crimes prosecution for severe 10%; therefore, ASD in psychiatric institution & court ordered to a violent/sexual crimes 18% overall in Sweden from 1998 forensic psychiatric being screened for autism, to 2001, all under institution AS, atypical autism prosecution for severe violent/sexual crimes (n = 100) Woodbury-Smith Screening of persons Self-report Individuals w/ASD Yes Violence history in et al. (2006) w/ASD in community questionnaire & (high-functioning 30% of ASD group, (n = 25) for history of Home Office autism & AS) living in similar to comparison violence using self-report Offenders’ Index the community group (25%) questionnaire & (UK) conviction data, compared to adult volunteers w/o ASD (n = 20) from local large company Continued on next page 20 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD Table 2 Continued Study Study type Violence-detection Subjects Comparison Findings method group w/o ASD? Allen et al. (2008) Survey-based (subjects Subject & informant Adults w/ASD recruited No Offending behavior & informants) study of surveys from independent (over 80% of which is prevalence of living, prisons, mental violent) in 26% of offending in 126 health facilities, adults w/ASD; comorbid adults with ASD (AS) specialist autism & psychiatric disorders from large geographical learning disability common (schizophrenia area of South Wales, services; included 25%, depression 12.5%, UK; AS diagnoses those diverted out of ADHD 18.75%); no confirmed with ASDI criminal justice evidence of clear systems association between ASD & offending (due to conflicting reports of ASD prevalence in general population) Mouridsen et al. Register-based study Conviction rates Adults (infantile autism, Yes Violence in 0.88% of (2008) comparing adults atypical autism, AS) infantile autism group, w/ASD (all former w/ASD in the 4.6% of atypical autism child psychiatric community group & 7.6% of AS inpatients; n = 313) group; differences with 933 controls from compared to controls general population significant only for (matched for age, arson (more common gender, place of birth, in AS) social group) on conviction rates for various crimes Langstrom et al. Register-based study Conviction rates Individuals w/ASD No, but Violent convictions in (2009) comparing historically (autism or AS) examined risk 7.3% of those w/ASD; violent & nonviolent hospitalized for factors for risk factors for violent individuals w/ASD various reasons violence among offending included (≥15 y.o.; n = 422) on individuals older age, male gender, sociodemographic with ASD AS diagnosis, comorbid variables & presence psychotic/substance of comorbid abuse/personality psychopathology disorders Bronsard et al. Comparison of Observer evaluations Intellectually disabled Yes 34%–58% of children (2010) aggression rate between (parent, day-care children & adolescents w/ASD showed 74 intellectually disabled provider, psychiatrist, w/ASD; controls aggression toward others children & adolescents nurse) using rating matched for age, (highest aggression ratings w/ASD & 115 typically scale for aggression gender, pubertal status made by day-care developing controls in toward others providers); aggression 3 observational situations more common in children (home, day care, during w/ASD (23%) compared blood-drawing); ASD to controls (0%) in diagnoses made by direct blood-drawing situation clinical observation using 29 32 DSM-IV &ICD-10, & confirmedwithADI-R Continued on next page Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 21 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Table 2 Continued Study Study type Violence-detection Subjects Comparison Findings method group w/o ASD? Kanne & Mazurek Multisite, Individual item Child & adolescent No, but Definite aggression 48 60 (2011) university-based study scores from ADI-R outpatients w/ASD examined risk (score of 2 or 3 on examining prevalence (autism, AS, factors for ADI-R aggression of, and risk factors for, PDD-NOS) aggression items) in 35.4% of aggression in children among youth children/adolescents & adolescents w/ASD with ASD w/ASD; risk factors (n = 1380) included younger age (6–11 y.o.), higher family income, parent-reported ASD-related social & communication problems, repetitive behaviors (specifically self-harming, ritualistic & resistance-to-change behaviors) Cheely et al. Examination of ASD/ Determination of Youth w/ASD in South No 5% (32/609) of youth (2012) DD database linked subjects charged Carolina ASD/DD w/ASD charged with with juvenile justice/ with a criminal database; 12–18 y.o.; criminal offenses; law-enforcement offense based on 1/3 intellectually compared to matched databases for prevalence linked autism & disabled comparison group of of criminal offending juvenile justice/ juvenile justice among youth w/ASD law-enforcement system–involved youth, (n = 609); ASD databases those w/ASD had diagnoses confirmed higher rates of crimes by record review against persons, lower using DSM-IV rates of probation violations & higher school-related offenses; however, no general population comparison group without ASD Mayes et al. Examination of Maternal ratings on Children w/ASD, 6–16 Yes Aggression (based on (2012) prevalence of explosive, behavioral scale y.o.; 302 maternal ratings) oppositional & w/high-functioning significantly more aggressive behavior in autism & IQ ≥ 80, 133 common in children 435 children w/ASD with low-functioning w/ASD (16.6%) compared to 988 autism & IQ < 80 compared to typically children w/other developing children clinical disorders & (0%), with no 186 typically significant difference developing children; between low- & diagnoses based on high-functioning ASD clinical evaluation groups; however, using the following: children w/ASD may DSM-IV; parent have been selected for interviews about early disturbance (referred to history; review of psychiatric clinic, treatment, school & whereas typically medical records; developing children scores on CASD; were not) testing observations Continued on next page 22 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD Table 2 Continued Study Study type Violence-detection Subjects Comparison Findings method group w/o ASD? Robinson et al. Screening of convicted Subjects were Male & female No 4% (97/2458) of (2012) prisoners (n = 2458) convicted prisoners prisoners, young & prisoners scored above from all 12 prisons in with mostly violent old; mean IQ = 92.5 cutoff on screening tool Scotland for ASD with offenses for ASD; however, of tool based on ASDI the 97 who did, only 33 & administered by agreed to further prison officers assessment using standardized measures 59 58 (AQ, ASDI ), and of these, only 2 scored above cutoff for ASD on AQ; none scored positive on ASDI; due to poor sensitivity & interrater reliability of tool, unclear if ASD in these prisons underrepresented or underdetected Mazurek et al. Examination of Single dichotomous Children & adolescents No, but Aggression in 53.7% of (2013) aggression prevalence item from parent w/ASD enrolled in examined risk individuals w/ASD; of in 1584 children & survey ATN; range of factors for these, self-injury, sleep adolescents w/ASD intellectual functioning aggression problems, sensory enrolled in multisite among youth difficulties were most ATN; ASD diagnoses with ASD strongly associated confirmed by clinical w/aggression interviews & ADOS; aggression measured by single dichotomous (yes/no) item from parent in ATN survey Keefer et al. Multisite, Individual items Children & adolescents No Aggression in 35% of 53 60 (2014) university-based study from ADI-R & w/ASD; ages 4–17; children & adolescents examining prevalence CBCL range of intellectual w/ASD; of these, small of aggression in 2648 functioning (mean but significant relationship children & adolescents IQ = 81.2) between repetitive w/ASD; diagnoses behaviors & aggression confirmed w/ADI-R &ADOS Hill et al. (2014) Examination of CBCL aggression Children & adolescents No, but Aggression in 25% of aggression prevalence scale w/ASD; ages 2–18; examined risk youth w/ASD; in 400 children & range of intellectual factors for aggressive children adolescents w/ASD functioning aggression w/ASD tended to have enrolled in Oregon among youth less severe overall & ATN; diagnoses with ASD social affect symptoms, confirmed w/ADOS; lower full-scale IQ, aggression measured more sleep difficulties, usingCBCLaggression internalizing problems scale & attention problems Continued on next page Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 23 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Table 2 Continued Study Study type Violence-detection Subjects Comparison Findings method group w/o ASD? Sondenna et al. Screening of all Subjects included Forensic evaluees No ASD in 1.4% (44/3382) (2014) forensic examination offenders who had charged with, or of evaluees; of these, reports(n= 3382)filed committed violent convicted of, variety of 33/44 (69% of evaluees in archives of or sexual offenses & offenses w/ASD) convicted of Norwegian Board of were referred for violent or sexual Forensic Medicine forensic psychiatric offenses; given that not over 10-year period investigation all of 3382 evaluees for ASD using who were charged ICD-10 criteria w/violent offenses were convicted, prevalence of ASD among violent offenders likely above 1% ADHD, attention-deficit/hyperactivity disorder; ADI-R, Autism Diagnostic Interview–Revised; ADOS, Autism Diagnostic Observation Schedule; AQ, Autism- Spectrum Quotient; AS, Asperger’s syndrome; ASD, autism spectrum disorder; ASDI, Asperger’s Syndrome Diagnostic Interview; ASD/DD, autism spectrum disorder—developmental disabilities; ATN, Autism Treatment Network; CASD, Checklist for Autism Spectrum Disorder; CBCL, Child Behavior Checklist; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th ed.; ICD-10, International Statistical Classification of Diseases, 10th rev.; PDD-NOS, per- vasive developmental disorder not otherwise specified; y.o., years old. The first direct effort to determine the prevalence of vio- subjects from Scragg & Shah’s study). Those scoring above lence in ASD was made by Ghaziuddin and colleagues, cutoff on an ASD screening questionnaire had their records who conducted an extensive, computer-based search of all reviewed for clinical information, including impairments in published articles on the clinical features of AS from 1944 social interaction, communication, repetitive/stereotyped ac- to 1990. Of a total sample of 132 patients, up to 5.6% were tivities, and special interests. Criteria for diagnosing ASD identified as having a history of violent behavior, comparable were equivalent to ICD-10 criteria. The authors found an to the age-matched rates of violent crime in the general popu- ASD prevalence of up to 5.3%. Two-thirds of the ASD group lation. They concluded that there was no association between met criteria for AS. Interestingly, those in the ASD group violence and AS. were significantly more likely to have a neurological condi- Scragg and Shah raised the possibility that Ghaziuddin tion (15/31), including brain pathology (8/15, comprising and colleagues’ prevalence estimates for violence in AS right hemisphere damage, right temporal lobe atrophy, pre- may be inaccurate due to underdetection of this diagnosis in frontal pathology, and unspecified hypoxic brain damage), prisons and secure settings. They screened the male population epilepsy (3/15), chromosomal disorders (2/15), and past (n = 392) of a maximum security hospital in England for evi- meningitis (2/15). The authors therefore suggested that dence of autistic-type behaviors. Those positive on the initial the presence of neuropathology may increase the likelihood record-based screen moved on to a second stage consisting of offending in individuals with ASD. of a semistructured interview with the key nurses (those A high forensic-setting rate of ASD was also found by most directly involved in the care of the patient) for those Siponmaa and colleagues, who retrospectively examined patients. In the third stage, patients were interviewed by the prevalence of child neuropsychiatric disorders in 126 an investigator. The authors found an AS prevalence (using offenders (aged 15 to 22 years) referred for forensic, pre- Gillberg and Gillberg criteria) of up to 2.3%. They noted sentencing psychiatric investigation over a five-year period that this rate was much higher than the general population in Stockholm. These investigations included evaluations by rate of 0.36% cited by Ehlers and Gillberg. Of note, this a psychologist, social worker, and psychiatrist. The result- latter estimate of community AS prevalence is significantly ing data sheets included information such as demographic lower than the recent Centers for Disease Control and Pre- data, early psychomotor development, child neuropsychiatric vention estimate of 1.47% of eight-year-olds in the United symptoms/signs over time, early traumatic experiences, sub- States having ASD—which suggests that the ASD rate in fo- stance abuse, past and current criminality, impulsivity, and rensic inpatients may not differ significantly (or at least as empathy. Based on DSM-IV, the authors found an ASD dramatically) from that in the general population. prevalence of 15%, with AS of 3%. 39 42 Expanding on Scragg and Shah’sefforts, Hare and col- Soderstrom and colleagues discovered similar forensic- leagues examined the prevalence of ASD in 1305 patients setting prevalence rates of ASD. They examined 100 adults residing in three secure hospitals in England (including the (aged 17 to 76) consecutively admitted by court order to a 24 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD forensic psychiatric institution, all of whom were under pros- toward detecting minor illegal behaviors), and the sample ecution for severe violent or sexual crimes. DSM-IV diagno- sizes were small. ses were assigned to all subjects using the Structured Clinical Mouridsen and colleagues used Danish register data to Interview for DSM-IVAxis I Disorders, Asperger’s Syndrome compare 313 adults (aged 25 to 59 at follow-up) with ASD Diagnostic Interview, and DSM-IV criteria for disorders not to 933 general population controls matched for age, gender, covered by the Structured Clinical Interview. They found an place of birth, and social group in terms of conviction rates. ASD prevalence of 18% (autism, 5%; AS, 3%; and atypical Rates of violence (combining “violent crimes,”“sexual autism, 10%). offending,” and “arson” as categorized separately by the au- Prison populations were examined by Robinson and col- thors) were 0.88% for the infantile autism group, 4.6% for leagues, who assessed 2458 prisoners for the presence of the atypical autism group (compared to 2.8% of controls), ASD using a screening tool completed by prison officers. and 7.6% for the AS group (compared to 3.2% of con- Ninety-seven of 2458 prisoners (4%) scored above the cutoff trols). Differences in violent crime rates between the ASD on the tool; however, when 32 of these prisoners were further and control groups were statistically significant only for assessed with standardized measures (the other 65 declined to arson; specifically, individuals with AS were significantly be interviewed), including the Autism Quotient and Asperger’s more likely than control individuals to have committed ar- Syndrome Diagnostic Interview, only 2/32 (6.25%) scored son (p < 0.0009). Among all individuals with ASD, 5.1% above the cutoff on the former, and none scored positive were convicted of violent crimes over the course of the ap- on the latter. The authors noted that the very low rate of proximately 30-year review period. The authors acknowl- ASD detected in their study could reflect the inadequate sen- edged that older diagnostic criteria (ICD-9) were used in sitivity of the screening tool, selection bias (with persons with making initial ASD diagnoses. ASD declining to be interviewed), or a low rate of ASD in the Langstrom and colleagues also used longitudinal re- prison population, possibly due to diversion into mental gisters to examine 422 individuals (aged 15 and older) with health settings. ASD (diagnosed primarily using ICD-10 criteria) hospital- Sondenaa and colleagues screened all forensic examina- ized between 1988 and 2000, and compared those commit- tion reports (n = 3382) filed in the Norwegian Board of Fo- ting violent offenses with those who did not on a number of rensic Medicine archives between 2001 and 2011 and found variables. They found that 7.3% of individuals with ASD a diagnosis of ASD (based on ICD-10 criteria) in 1% of were convicted of violent offenses. They noted that risk fac- the sample. Considering that a portion of the forensically ex- tors for violent offending included older age, male gender, a amined individuals had not committed violent or sexual of- diagnosis of AS (as opposed to autistic disorder), and comor- fenses, the ASD prevalence among violent/sexual offenders bid psychotic, substance use, and personality disorders. They was therefore somewhere above 1%. commented that violent individuals with ASD had the same While the above prevalence studies indicate that ASD is sociodemographic and comorbidity features as violent per- generally overrepresented in forensic settings—which suggests sons without ASD. Among those with comorbid disorders, diagnostic underdetection and the possibility that individuals violence occurred in 18% of those with schizophrenia, 33% with ASD might be more prone to violence—sample-selection of those with personality disorders, and 71% of those with issues must be considered (e.g., forensic psychiatry samples substance use problems. While their study employed a much often produce higher rates of ASD, as these subjects are likely larger sample than that of Woodbury-Smith and colleagues to have mental health needs of some kind). and was one of the first to examine violence-risk factors To that end, Woodbury-Smith and colleagues examined among individuals with ASD, subjects were selected based the prevalence of offending among men and women with on being hospitalized and therefore may not be representa- ASD (AS/high-functioning autism) living in the community. tive of individuals with ASD living in the community. More- Inclusion criteria included meeting ICD-10 diagnostic cri- over, like the study of Mouridsen and colleagues, violence teria for an ASD (confirmed with the Autism Diagnostic was measured via conviction rates, which may have produced Interview–Revised [ADI-R]) and having a full-scale IQ of underestimates. 70 or above on the Wechsler Abbreviated Scale of Intelli- Allen and colleagues used subject and informant surveys gence. Twenty-five adults with ASD were compared to to examine 126 adults with ASD (AS, confirmed using the 20 adult volunteers without ASD recruited from a local large Asperger’s Syndrome Diagnostic Interview) from a large company. Subjects completed a self-report questionnaire re- geographical area of South Wales and found offending be- garding behaviors that could lead to arrest by the police, havior (over 80% violent) in 26%. Like Langstrom and prosecution, and conviction. Information was also obtained colleagues, the authors noted that comorbid psychiatric on convictions within the ASD group from the Home Office Of- disorders were common, including schizophrenia (25%), de- fenders’ Index (UK). Thirty percent of the ASD group reported a pression (12.5%), and attention-deficit disorder (18.75%). history of violent behavior, similar to the comparison group Subsequent prevalence studies have focused on younger (25%). However, “violent behavior” was unclearly defined populations with ASD. For example, Bronsard and colleagues (the authors noted that their self-report measure was too biased compared 74 intellectually disabled youth with ASD to 115 Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 25 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im typically developing controls in terms of aggression toward probation violations, and higher rates of school-related of- others in three observational situations. ASD diagnoses were fenses. The authors speculated that individuals with ASD 29 32 based on DSM-IV and ICD-10 criteria and confirmed may be more likely to lash out violently during an altercation, with the ADI-R. Based on parent and day-care provider less likely to violate probation due to increased rule adher- evaluations, respectively, 34% and 58% of children with ASD ence, and more likely to deal problematically with the social displayed aggression toward others. Individuals with ASD were demands of a school setting. also more aggressive (23% vs. 0%) during a blood-drawing Mazurek and colleagues expanded the scope of the situation, which the authors interpreted as suggesting poorer 2011 Kanne and Mazurek study by looking at 1584 chil- coping skills when faced with stress in persons with ASD. dren and adolescents enrolled in a network of autism treat- Kanne and Mazurek studied the prevalence of, and ment centers across Canada and the United States. The risk factors for, aggression in 1380 children and adolescents authors verified ASD diagnoses with clinical interviews with ASD in a multisite, university-based study. Core ASD and the ADOS, and measured aggression with a single di- symptoms were assessed using the ADI-R, Autism Diag- chotomous (“Yes” or “No”) item from a parent survey. nostic Observation Schedule (ADOS), Social Respon- They found current physical aggression in 53.7% of subjects, 63 64 siveness Scale, and Repetitive Behavior Scale–Revised. most strongly associated with self-injury, sleep problems, and “Aggression” was assessed based on individual item scores sensory difficulties. However, the measure of aggression used from the ADI-R. They found that 35.4% of subjects with (parent report on a single dichotomous item) may have in- ASD demonstrated definite aggression toward others. They flated the reported rate. also found that aggression was associated with younger Keefer and colleagues noted an aggression rate of 35% age(highestinthe under6,6–8, and 9–11 age groups), higher among 2648 children and adolescents with ASD who were family income, parent-reported social and communication part of a multisite, university-based sample. The subjects problems (as measured by the Social Responsiveness Scale), had a range of intellectual functioning. Diagnoses were con- 60 62 and repetitive (including self-injurious, ritualistic, and resistance- firmed with the ADI-R and ADOS. They noted a signifi- to-change) behaviors. They noted that these findings are con- cant, but small, relationship between restricted/repetitive sistent with work by Reese and colleagues, who found that behaviors and aggression, with larger effect sizes observed autistic children, compared to non-autistic peers, displayed when using teacher report. disruptive behavior to escape demands that impeded perfor- Finally, Hill and colleagues looked at 400 children (aged mance of a repetitive behavior, to maintain access to items 2 to 18) enrolled in a multisite treatment network with a diag- used in a routine, or to avoid sensory stimuli. They posited nosis of ASD supported by administration of the ADOS. that caregiver attempts to discourage certain repetitive be- They found an aggression prevalence (using the Child Be- haviors could trigger reactive aggression from individuals havior Checklist Aggressive Behavior scale) of 25%, with with ASD, accounting for the association between repetitive aggressive children tending to have less severe overall and behaviors and aggression. Case reports by White and col- social-affect ASD symptoms, lower full-scale IQ scores, and leagues support this possibility. more sleep difficulties, internalizing problems (including anx- Mayes and colleagues compared 435 children with ASD iety), and attention problems compared to non-aggressive (aged 6 to 16, with a range of intellectual functioning) to 186 children with ASD. typically developing children in terms of aggression rates. In summary, prevalence studies have aimed to more quan- ASD diagnoses were based on DSM-IV criteria, using the titatively evaluate the association between ASD and violence. following: parent interviews about early history and current One of these, based on a review of all published case re- symptoms; reviews of treatment, school, and medical records; ports, found no significant association between ASD and vi- 66 38 scores on the Checklist for Autism Spectrum Disorder; and olence. Another four studies found an overrepresentation observations of the child during psychological testing. Ag- of ASD in forensic settings, with prevalence rates ranging 39–42 gression (as determined by maternal ratings) occurred in from 1.5% to 18%. Community-based studies have re- 16.6% of children with ASD compared to 0% of typically ported violence rates of 5.1% to 58% among individuals with 43–50,52–54 developing children, with no significant difference between ASD. Given the potential selection biases inherent the low-functioning and high-functioning ASD groups. How- in forensic prevalence studies and the lack of significant dif- ever, those with ASD had been referred to a psychiatry clinic ference from (or the absence of) normal population compar- and thus may have been selected for disturbance. ison groups in most community-based prevalence studies, Cheely and colleagues examined data from linked autism these reports have not conclusively shown individuals with and juvenile justice/law enforcement databases and found that ASD to be more violent than individuals without ASD, of 609 youth (aged 12 to 18) with ASD (about one-third of with the possible exception of such persons having a higher whom had intellectual disability), 5% were charged with risk of committing arson (based on one prevalence study). criminal offenses. Compared to a matched comparison group Several risk factors for violence in persons with ASD were 40,44,46,48,49,52–54 of juvenile justice system–involved youth, those with ASD identified and will be discussed later in had higher rates of crimes against persons, lower rates of this review. 26 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD Table 3 Previous Reviews on Relationship Between Violence and Autism Spectrum Disorder Author Findings Theoretical explanation for violence in autism spectrum disorder Silva et al. (2004) Based on overrepresentation of ASD in forensic settings, Theory-of-mind deficits, weak central coherence, ASD pathology is a risk factor for criminal behavior; history of neglect may contribute to development of ASD may be implicated in the development of serial-killing behavior in some individuals with ASD some serial killers Weak central coherence may allow some serial killers to separate homicidal behavior from other aspects of their lives History of neglect may allow formation of closed psychological infrastructures in which maladaptive fantasies can thrive, unhindered by parental feedback Newman & Unclear if violence more prevalent in AS compared to Comorbid psychiatric disorders raise risk of violent Ghaziuddin (2008) general population, but 29.7% of violent individuals offending among individuals with AS w/AS had evidence of definite psychiatric disorder, & 54% had evidence of probable psychiatric disorder Bjorkly (2009) No empirical evidence to support or refute possible Violence in AS may be driven by deficiency in link between AS & violence emotional empathy (ability to feel compassion for, or be emotionally involved with, victim) & impairment Among violent persons w/AS, motives included in social interaction (including misinterpretation, coping misinterpretation of others’ intentions in 35%, sensory failure, hypersensitivity to sensory stimuli) hypersensitivity in 21%, sexual frustration & empathic failure to respect others’ integrity in 10%, & others’ disruptions of AS preoccupations in 7% Cashin & Newman Significant proportion of ASD among individuals “Real triad of impairment” in ASD consists of impaired (2009) in custody undetected/misdiagnosed theory of mind, impaired abstraction & visual—as opposed to linguistic—processing, leading both to ASD symptoms such as obsessive-compulsive features or inability to form unified, centrally coherent base of impaired social skills increases vulnerability to bullying, knowledge about the world, & to deficient empathy exploitation, social isolation Limited research on experience of individuals w/ASD in prisons Browning & Overrepresentation of individuals with ASD in criminal Theory-of-mind deficits or intense preoccupation Caufield (2011) justice system could reflect social circumstances, with narrow interests are predominant factors behind comorbid mental health issues, inadequate recognition/ offending in individuals w/ASD understanding of ASD by criminal justice agencies, impaired ability of persons w/ASD to escape detection Community studies have shown no significant association between ASD & offending Gunasekaran & No increased risk of offending in people with ASD Comorbid psychiatric disorders (including psychotic, Chaplin (2012) compared to those without ASD personality, substance abuse) & lack of empathy/ability to recognize fear may increase violence risk among Lower-functioning subgroups w/ASD may have lower individuals w/ASD prevalence of offending than general population Higher-functioning ASD subgroups (AS, atypical autism) more likely than lower-functioning ASD subgroups to engage in arson, sexual offending & stalking Lerner et al. (2012) No increased risk of violent criminal activity among Violence in individuals with high-functioning individuals with high-functioning ASD, but possibly ASD due to deficits in (1) theory-of-mind abilities, “some extant relationship that should be considered” (2) emotion regulation & (3) internal moral reasoning Mouridsen (2012) No increased risk of offending in people with Comorbid psychiatric disorders (including psychotic & ASD compared to those without ASD personality disorders) & impaired ability to recognize fear in others may raise risk of offending in ASD Continued on next page Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 27 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im Table 3 Continued Author Findings Theoretical explanation for violence in autism spectrum disorder King & Murphy Although ASD appears overrepresented in offender Mood disturbances, social deficits & poor emotional (2014) populations, 5 of 7 prevalence studies looking at ASD in coping skills significant factors in offending behavior offender populations used biased samples; the other 2 among individuals w/ASD studies (which did not use biased samples) employed poor diagnostic methods for ASD Equal or lower rates of offending among those with ASD compared to those without ASD Although trend toward higher comorbid psychotic & personality disorders among those w/ASD who offend, studies reviewed were of people in mental health settings (i.e., selection bias) Matson & Adams Aggression “very frequent,” occurring in over Poor emotion regulation, social/communicative deficits, (2014) half of individuals w/ASD (based on findings of searching for tangible items & wish to escape from Mazurek et al.) undesired tasks/environments all contribute to aggression in individuals w/ASD AS, Asperger’s syndrome; ASD, autism spectrum disorder. In examining the relationship between ASD and violence, as a factor in ASD-related violence but, in contrast to Bjorkly’s a third source of information can be found in previous re- emphasis on its emotional aspects, saw such empathy defi- views on this topic, many of which conclude by proposing ex- ciency as the result of core cognitive-processing deficits. They planations for violent behavior in ASD. described a “real triad of impairment” in ASD consisting of impaired abstraction, impaired theory of mind, and visual, as Reviews with Proposed Explanations for Violence in ASD opposed to linguistic, processing, which results in an inability Table 3 summarizes previous reviews that have been pub- to form a centrally coherent base of knowledge about the lished on the association between ASD and violence. Ten such world and in a marked deficit in empathy. reviews were found. In line with Cashin and Newman’s hypotheses, Silva Newman and Ghaziuddin reviewed all published arti- and colleagues reviewed the literature on ASD and violence cles reporting an association of AS with violence. Of 37 and inferred that theory-of-mind deficits, weak central co- cases that met inclusion criteria, 31 (83.7%) had evidence herence, and a history of neglect may contribute to the devel- of a definite or probable psychiatric disorder, including opment of serial-killing behavior in some individuals with attention-deficit/hyperactivity disorder, depression and other ASD. They proposed that weak central coherence may allow mood disorders, “obsessional neurosis,” and disorders resulting serial killers with ASD to compartmentalize their life experi- in maximum-security hospitalization. They concluded that ences by separating their homicidal behavior from other im- most violent individuals with AS suffer from comorbid psy- portant aspects of their lives, and that a history of neglect chiatric disorders that raise their risk of offending, as they may allow future serial killers with ASD to harbor maladap- tive fantasies unhindered by parental feedback. do in the general population. 70 72 Browning and Caufield also linked offending behavior in Bjorkly also reviewed the literature and found that of 29 violent ASD-related incidents, 35% were driven by so- ASD to theory-of-mind deficits. They added that while indi- cial misinterpretations of others’ intentions, 21% by sensory viduals with ASD appear to be overrepresented in the crimi- hypersensitivity, 10% by a combination of sexual frustration nal justice system, the overrepresentation could reflect social and empathic failure to respect others’ integrity, and 7% by circumstances, comorbid mental health issues, and impaired others’ disruptions of AS-related preoccupations. He con- ability to escape detection. cluded that no empirical evidence either supported or re- Theory-of-mind deficits were likewise cited as one compo- futed a link between AS and violence, and that AS-related nent in ASD-related violence by Lerner and colleagues. violence may be driven by empathy deficiency (specifically These authors proposed that a triad of deficits in (1) theory- an impaired ability to feel compassion for, or be emotionally of-mind abilities, (2) emotion regulation, and (3) internal involved with regard to, the victim) and impairment in social moral reasoning may explain how violent criminal behavior interaction. may emerge in individuals with high-functioning ASD under Cashin and Newman, in reviewing the relationship be- conditions of conflict or ambiguity. They noted that moral tween autism and criminality, also noted deficient empathy reasoning in these individuals may represent a “hacked-out” 28 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD process whereby such persons are able to respond to previ- overrepresentation reflects greater violence among individ- ously learned morally relevant scenarios but are unable to uals with ASD. Community studies reported a wide range of make such distinctions in new and unfamiliar situations. Re- violence rates (5% to 58%) among individuals with ASD, garding the second domain, emotion regulation was also cited reflecting variations in violence-detection methods and popu- by Matson and Adams as a contributory factor in ASD- lations studied. Many of these studies (six out of ten) did not related violence. include comparison groups of individuals without ASD, and 75 73 43,45 Mouridsen and Gunasekaran and Chaplin both con- of the four that did, two showed no significant difference cluded that people with ASD do not appear more likely to of- in violence rates between those with and without ASD (with fend than people without ASD, but that among individuals the possible exception of arson in one study). The remain- with ASD, comorbid psychiatric diagnoses (including psy- ing two studies reported greater violence in persons with chotic and personality disorders) and an impaired ability to ASD compared to controls, but one had sampling biases recognize fear in others may raise the risk of offending. and the other used informants (day-care providers) who Gunasekaran and Chaplin added that higher-functioning may have had different tolerance levels for aggression, and ASD subgroups (e.g., AS and atypical autism) are more likely used an intrusive, anxiety-provoking situation to measure ag- to engage in arson, sexual offending, and stalking compared gression in a severely impaired ASD sample. Therefore, on to lower-functioning ASD subgroups, in whom criminal the whole, prevalence studies have provided no persuasive ev- damage is more common. idence that individuals with ASD are more violent than those Finally, King and Murphy noted that among offender without ASD. The issue of arson deserves further explora- populations, ASD appears to be overrepresented but that tion, as one prevalence study suggested a higher risk of arson most studies of these populations have used biased samples among individuals with AS, and case reports have de- 5,12,18,22 selected for psychopathology. They also noted that well- scribed such behavior in AS. controlled studies showed that people with ASD were Ten previous reviews indicate that individuals with equally or less likely to offend than people without ASD. ASD are no more violent than those without ASD. The au- They commented that despite a trend toward higher rates thors of those reviews have overall posited three main ex- of psychosis and personality disorder in individuals with planatory (or generative) factors that may underlie violent ASD who offend, the studies they reviewed were all con- behavior in persons with ASD: (1) comorbid psychopathol- ducted in mental health settings, which are likely to include ogy, (2) deficits in social cognition (to include impairments people with multiple diagnoses. They added that—based in theory-of-mind abilities and empathy); and (3) emotion- on input from individuals with ASD in the criminal justice regulation problems. These factors have gained preliminary 78–80 system—social-functioning deficits, mood disturbances, empirical support. and poor emotional-coping skills were significant factors Turning from the question of whether individuals with in offending behavior. ASD are more violent than those without ASD, the issue of In summary, ten previous reviews on the relationship be- which individuals among those with ASD are at greater risk 40,44,46,48,49,52–54,70 tween ASD and violence indicate that individuals with ASD for violence was examined in nine studies. are no more violent than those without ASD. The authors Risk factors identified in these studies include younger age 48 46 46 of those reviews have collectively posited three main factors (6–11 years old), older age (26 and older), male gender, 46 48 that may underlie violent behavior in persons with ASD: having a diagnosis of AS, higher parental income, parent- (1) comorbid psychopathology, (2) deficits in social cognition reported social and communication problems (as measured 63 48 (to include impairments in theory-of-mind abilities and empa- by the Social Responsiveness Scale ), less severe overall 62 54 thy), and (3) emotion-regulation problems. and social affect symptoms (as measured by the ADOS ), 48,54 54,70 repetitive behaviors, sensory difficulties, comorbid psychiatric disorders (including psychotic, personality, and DISCUSSION 44,46 40 This review has attempted to provide an update on the litera- substance use disorders), comorbid neuropathology, 52,54 ture regarding the association between violence and ASD, and sleep difficulties. taking into account information from descriptive case reports, Regarding some of these risk factors, older age was noted prevalence studies, and previous reviews. by Langstrom and colleagues to be likely related to the Case reports have described individuals with ASD com- cross-sectional nature of their study and the greater likelihood mitting a range of violent acts. Many have posited features of an individual appearing in cumulative crime registers over of ASD that could increase the likelihood of such acts, includ- time. The higher risk in individuals with AS compared to ing the following: impaired theory-of-mind abilities; difficulty those with other forms of ASD is likely due to relatively intact appropriately perceiving nonverbal cues; intense, restricted intellectual capacity and ability to communicate (albeit inap- interests; and comorbid psychiatric disorders. propriately) in the former, along with tighter supervision Regarding prevalence studies, those conducted in foren- of the latter. Higher parental income lacks an obvious expla- sic settings generally found an overrepresentation of ASD, nation as a risk factor, though Kanne and Mazurek specu- but selection biases undercut any conclusions that this lated that higher-income families may have more access to Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 29 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im interventions that challenge (and frustrate) children with Social-Cognition Deficits ASD, possibly precipitating more aggression. Higher parent- Baez and colleagues found that adults with AS showed sig- reported social and communication deficits (as measured by nificant impairments compared to matched healthy controls the SocialResponsivenessScale) as a risk factor makes intu- on tasks measuring theory of mind, empathy, emotion re- itive sense, as such difficulties would seem to predict problem- cognition, and self-monitoring in social settings. By contrast, atic behaviors. The disparity between this finding and the adults with AS performed as well as controls on tasks in observation that less severe overall and social-affect ASD which situational elements were clearly defined (including a symptoms, as measured by the ADOS, increased violence moral judgment task in which information about intention, risk requires explanation; it may be that the Social Respon- outcome, and context was explicitly presented). Based on their siveness Scale reflects broader ASD-related functioning that is findings, Baez and colleagues recommended (1) traditional better captured by parent report, whereas the ADOS focuses social-skills training programs that incorporate naturalis- on core symptoms specific to an ASD diagnosis, as noted by tic environments to enhance skill application and that aim at Kanne and Mazurek. Comorbid neurological disorders teaching explicit rules to help individuals with ASD build re- could cause disruption of brain circuits (e.g., prefrontal, lim- lationships with others, and (2) programs that also teach im- bic) involved in the control of aggression, increasing violence plicit rules for interpreting unpredictable social contexts. risk. Sleep difficulties as a risk factor could be related to co- One promising intervention for individuals with ASD morbid psychopathology or to fatigue-based exacerbation that takes into account the need to assess contextual cues of impaired emotion regulation in ASD. was examined by Stichter and colleagues, who developed An interesting question concerns the extent to which risk a group-based Social Competence Intervention, based on factors for violence in the general population are relevant to cognitive-behavioral principles, to target deficits in theory of individuals with ASD. In typically developing individuals, mind, emotion recognition, and executive function in 27 stu- risk factors for violence include male gender, younger age, dents aged 11 to 14 with ASD (AS/high-functioning autism). lower intellectual functioning, early language delays, low The curriculum included skill instruction, modeling, and family income, low parent education levels, maternal antiso- practice in structured and naturalistic settings. Topics included cial behavior, early maternal onset of childbearing, poor facial-expression recognition, sharing ideas with others, turn school performance, delinquent peers, living in a disadvan- taking in conversations, recognizing feelings/emotions of self taged neighborhood, and comorbid psychiatric disorders and others, and problem solving. All students showed signif- 54,69,81 and substance abuse. Based on the results of this re- icant improvement on parent-reported social skills and exec- view, it appears that some of these risk factors apply to indi- utive functioning. Significant growth was demonstrated on viduals with ASD (e.g., male gender, younger age, comorbid direct assessments of theory of mind, facial-expression recog- psychiatric disorders, and substance abuse), some do not nition, and problem solving. (early language delays, low family income), and some have Stichter and colleagues subsequently adapted the Social an unclear impact at present (lower intellectual functioning, Competence Intervention to meet the needs of elementary maternal antisocial behavior/early onset of childbearing, peer school students. Using a similar format and curriculum in and neighborhood factors). 20 students aged 6 to 10 with AS/high-functioning autism, How can these explanatory and associational risk factors they found significant improvements on parent-perceived help us in terms of preventing violence among individuals overall social abilities and executive functioning, and on direct with ASD? assessments measuring theory of mind and problem solving. Other researchers (e.g., Donoghue et al.) have also noted the potential efficacy of cognitive-behavioral therapy in treating youth with AS. IMPLICATIONS FOR TREATMENT AND PREVENTION OF VIOLENCE IN PERSONS WITH ASD Emotion-Regulation Problems If we presume the above-noted explanatory factors contribute Samson and colleagues found that on measures of emotional to violence in individuals with ASD, it is worth exploring functioning, 27 individuals with ASD (AS/high-functioning how such deficits may be treated in order to minimize vio- autism) reported higher levels of negative emotion, greater lence risk. Possible treatment approaches are discussed below. difficulty identifying and describing their emotions, less use of cognitive reappraisal, and more use of emotional suppres- Comorbid Psychopathology sion (a less adaptive emotion-regulation strategy) compared As noted, many individuals with ASD who commit violent to controls. The authors suggested that affective functioning acts have been shown to have comorbid psychiatric disor- in individuals with ASD could be improved by the use of tech- 4,15,69 ders. Careful assessment and treatment of these disorders niques that enhance their ability to attend to and discriminate based on current standards of practice (e.g., APA practice emotions and by strategies that increase their ability to respond guidelines) are crucial in helping to mitigate the increased vio- flexibly to emotions by encouraging cognitive reappraisal. They lence risk that these illnesses confer on individuals with ASD. noted promising research in ASD that has been conducted to 30 www.harvardreviewofpsychiatry.org Volume 24 � Number 1 � January/February 2016 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Update on Violence in ASD 88 89 addressstressmanagement, anger management, and emo- discussed earlier warrant consideration. Take the following tion regulation, including the use of cognitive-linguistic strate- hypothetical example: 90 91 gies and “thinking tools.” A 14-year-old boy diagnosed in the past with AS is Kaartinen and colleagues similarly noted problems with sent home from school after yelling at his mathematics emotion regulation resulting in more severe reactive aggres- teacher and leaving drawings of buildings being blown sion in boys with ASD compared to boys without ASD in re- up on the teacher’s desk. General clinical assessment re- sponse to minor aggressive attacks, concluding that behavioral veals a history of depression. The boy was suspended and cognitive interventions were important to help these boys from school last year after hitting a peer (whom he learn more assertive, rather than aggressive, responses to conflict. claims intentionally bumped him playing soccer). He In line with the findings and recommendations of Samson, 92 93–96 denies current suicidal or homicidal ideation but Kaartinen, and their colleagues, various researchers expresses anger that his math teacher “completely have explored the utility of dialectical behavior therapy in misrepresented the concepts” during class. He admits individuals with intellectual disabilities, some of whom were to drawing the pictures in question, stating he has al- diagnosed with ASD. This research has looked at various ways been fascinated with “disintegration.” His fa- populations, including aggressive, intellectually disabled adults ther (a software designer) and mother (a radiologist) living in supervised residential settings and adult offen- 95,96 note the boy’s long history of difficulty making and ders. These reports provide preliminary promise for maintaining friends, oversensitivity to noise, and repet- dialectical behavior therapy in helping to foster effective itive hand-twirling. emotion-regulation strategies in individuals with ASD. Mind- fulness strategies have also been reported to help individuals This boy’s associational risk factors for ASD-related vi- with ASD effectively manage negative emotions that trigger olence include his male gender, young age, AS diagnosis, aggression. high parental income, parent-reported social-interaction Biologically based interventions have been explored to difficulties, history of sensory abnormalities, and repetitive treat the emotion-regulation (and social-cognitive) deficits as- behaviors. Based on these factors, an examination of genera- sociated with ASD. Thompson and colleagues reported sig- tive factors shows that he has a comorbid psychiatric disor- nificant EEG differences between individuals with AS and der (depression). Assessment of additional generative factors controls in the frontal, temporal, and temporal-parietal (mirror could entail psychometric testing to assess the domains of the- neuron) areas of the brain, with abnormal activity originating ory of mind, empathy, and emotion regulation. If deficits are from the anterior cingulate, amygdala, uncus, insula, hippo- revealed, his generative risk factors for violence could be ad- campal gyrus, parahippocampal gyrus, fusiform gyrus, and dressed via psychotherapeutic or pharmacologic intervention orbitofrontal or ventromedial areas of the prefrontal cortex. for his depression, Social Competence Intervention (or other In a second report, given that the functions of these brain cognitive-behavioral therapy–based approach) for his social areas correspond to deficits seen in AS, Thompson and col- cognitive deficits, and possible dialectical behavior therapy leagues suggested using neurofeedback training to target for problems with emotion regulation. symptoms such as difficulty reading and mirroring emotions, poor self-regulation skills, anxiety, and inattentiveness. Based on data from neurofeedback training in 150 clients with AS FUTURE RESEARCH seen over a 15-year period, the authors found significant To ascertain whether individuals with ASD are more violent improvements on measures of core AS symptoms, including than those without ASD and whether the proposed genera- difficulties with social functioning and anxiety. tive factors increase their violence risk, a future study should Biological interventions have also included pharmaco- undertake a prospective, community-based comparison of logic approaches. For example, the second-generation an- two groups: individuals with ASD and those without ASD, 100,101 102 tipsychotics risperidone and aripiprazole have matched for age, gender, education level, socioeconomic sta- shown efficacy in treating aggression and irritability in tus, and presence of comorbid psychiatric and neurological children and adults with ASD, and selective serotonin re- disorders. Clarity in the diagnostic criteria used for ASD, uptake inhibitors (e.g., fluoxetine) have shown benefit for the makeup of the ASD sample (proportion of subjects with ritualistic/repetitive behaviors in adults with ASD. Infor- DSM-IV autistic disorder, Asperger’s disorder, etc.), and the mative reviews on ASD-related medication treatments have definition of violence would be important. Within the ASD 104,105 been published. group, baseline and follow-up psychometric testing to assess the realms of social cognition and emotion regulation should PRACTICAL APPLICATION be performed. Violent incidents could be tracked via informant/ How should a clinician assess an individual with ASD in self-report and legal records. It could then be examined whether terms of his or her risk for violence and the possible need to more violent incidents were reported over time in the ASD intervene to mitigate that risk? In addition to the risk assess- than in the comparison group, and within the ASD group, ment included in a standard psychiatric evaluation, the factors whether violent individuals were more likely to evidence Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 31 Copyright © 2015 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. D. S. Im deficits in social cognition and emotion regulation than non- evaluation, treatment and prevention, and potentially pro- violent individuals. vide compelling empirical support for forensic testimony Such a study would also have potential forensic implica- regarding defendants with ASD charged with violent crimes. tions. An expert may have difficulty stating the empirical basis for his or her conclusion that ASD-related deficits Declaration of interest: The author reports no conflicts of were instrumental in driving a defendant’s violent behav- interest. The author alone is responsible for the content and ior. If future research confirms the relevance of the above- writing of the article. noted generative factors in increasing ASD-related violence risk, such information could be referenced in solidifying em- The author thanks Luke Tsai, MD, for his input on this pirically supported explanations for violence in defendants manuscript. with ASD. REFERENCES LIMITATIONS 1. Asperger H, Frith U, trans. Autistic psychopathy in childhood. This review has a number of limitations. First, methodologi- . In: Frith U, ed. Autism and Asperger syndrome. Cambridge: cal differences among the prevalence studies cited—including Cambridge University Press, 1991. differencesinhow “violence” was defined and measured, 2. Mawson D, Grounds A, Tantam D. Violence and Asperger’s syndrome: a case study. Br J Psychiatry 1985;147:566–9. “type” of ASD examined (e.g., autism, AS), subject source, in- 3. Baron-Cohen S. 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